The Acute Medical Unit (part of the hospital’s emergency
services) started offering opt-out HIV testing to adult patients in 2011. Just
over 4000 patients were tested during a 21-month period – representing one
third of patients admitted to the unit.

Twenty people were diagnosed with HIV during this time. This
amounts to a prevalence of around 0.5% in those tested (similar to the
prevalence in the local community). HIV testing is usually thought to be
cost-effective if 0.1% or more people test positive.

A third of the diagnoses would have been missed if only
people with clinical indicator diseases had been tested.

In high-prevalence areas, more widespread
implementation of opt-out testing in acute settings could make an important
contribution to reducing the levels of undiagnosed infection and late
diagnosis. The Croydon findings show that
the testing policy is acceptable, feasible, sustainable and
cost-effective.

The researchers attribute the success of the policy to close
support during the early stages from members of the hospital’s HIV team,
ownership of the policy by Acute Medical Unit staff (despite high staff
turnover), and the enthusiasm of nurses, who eventually took the lead in implementing
the policy.

After statistical adjustment, male sex workers were over
three times more likely to be diagnosed with HIV than other men, and also more
likely to have chlamydia or gonorrhoea. Male sex workers attended sexual health
clinics more often than other men, and were more likely to have a full sexual
health screen.

Whereas it’s often assumed that male sex workers are mostly
young men, in fact these men were slightly older than other clinic attendees –
30% were over 35 years old.

Almost two-fifths had moved to the UK from elsewhere, primarily countries in South
America and in Europe. In terms of sexual
orientation, three-quarters of the migrant men identified as being a man who
has sex with men, but only a third of the British-born men did so.

This
study points to the need for investment in HIV prevention work with men who
sell sex.

The intervention used tablet computers and involved the user
being asked a series of questions about health and lifestyle, given
personalised feedback and shown videos in which peers demonstrate healthy
behaviours, with the user asked to develop a personalised plan for better
adherence or safer sex. A mix of health behaviour theories were used to develop
the content.

Topics included treatment adherence, viral load, HIV
disclosure, condom use and drug use. The intervention was delivered every three
months over a nine-month period, usually during people’s regular clinic visits.

Participants in the control group received standard care.

At the end of the study, fewer people in the intervention
group reported instances of unprotected sex, or of problems using condoms – a
change that was not seen in the control group.

The
intervention also had an impact on participants’ viral load and self-reported
adherence, especially in those participants who had a detectable viral load to
begin with. Also, most participants completed the programme and said it was as
good as face-to-face sessions.

The researchers analysed the sexual risks that men took (measured
every six months) and allocated the participants to three groups.

One-in-seven men belonged to a very high risk group, 32% of
whom became infected with HIV over the study period. While men who had
high-risk behaviours in one six-month period most often continued to do so in
the following six months, this was not always the case. Men went in and out of
being at risk of HIV as their relationship status changed or as they adopted
different sexual practices.

Just under a quarter belonged to a moderate risk group, of
whom 10% became HIV positive.

The other two-thirds were at low risk of HIV, except for
short periods of time – 3% of them acquired HIV.

The
researchers did this analysis because they wanted better information that could
help clinicians to provide pre-exposure prophylaxis (PrEP) to men who have
‘seasons of risk’. PrEP is only likely to be cost-effective if it is taken by
people with the highest risk of infection. But the study is of broader interest
as it is the first to document gay men’s ‘risk careers’ over a long
period of time and in such detail.

People attending a sexual health clinic were asked to
recruit up to five individuals in their social network for a health promotion
programme. This covered a wide range of health issues, and included HIV
testing.

Around half of the ‘index patients’ did recruit at least one
person, most often a friend or neighbour. Only one-in-ten contacts were sexual
partners.

When index patients had themselves been newly diagnosed with
HIV, one third of their contacts tested HIV positive. This partly reflects the
very high prevalence of HIV in Malawi,
but also the likelihood that individuals with higher-risk behaviours know other
people with similar behaviours. A control group of index patients, recruited in
the local community, encouraged more people to test, but had fewer contacts
with undiagnosed HIV.

In order to identify one new case of HIV, it was necessary
to screen eight contacts of the HIV-positive index patients; ten contacts of
index patients who had an STI but not HIV; and 18 contacts of the community
controls.

This approach offers an alternative or supplement to
traditional partner notification. Similar
interventions have already been tested in urban areas of the United States –
they have been shown to help identify people with undiagnosed HIV who may be
otherwise hard to reach.

Related links

Case study: online engagement with Africans

It is often thought that web-based interventions about HIV
are less likely to reach black African people than other groups, but the
success of HIV Prevention England’s online engagement work shows that barriers
can be overcome.

Some
research suggests that black Africans are actually more likely to have
internet access than other UK
residents. But a challenge for health promoters is identifying websites which
can reach an African audience.

“Africans are using online media but they are scattered,”
says Takudzwa Mukiwa of Terrence Higgins Trust. The most popular websites are
the same as for other ethnic groups (Daily
Mail, You Tube, etc.) but advertisements would be expensive and could not
target an African audience. There are African-focused websites but they are
often specific to citizens of one country or more likely to be used by people
overseas than UK
residents.

However, Facebook is extremely popular and facilitates
targeted advertising, as well as sharing of content between friends.

For the It Starts With
Me campaign, there are two Facebook pages, one primarily for African
audiences and the other aimed
at gay men. The African page is almost as popular as the gay page – 5681
people have ‘liked’ it. During November (which included National HIV Testing Week) just
under 13,000 people engaged with the page in some way – for example, by sharing
a link, taking part in an online discussion or completing a quiz about HIV
testing.

In order to use advertising in a cost-effective way,
advertisements only appear on certain Facebook users’ pages. An English
location, an age range and a gender can be specified. These factors are
combined with a long list of ‘interests’ which are more likely to be expressed
by African people than others – for example, African musicians, politicians,
cities and regions.

This has been developed through trial and error, as has
identifying the types of content which users engage with. While some HIV
awareness themes and discussions about relationships are popular, material
discussing safer sex has led some people to ‘unlike’ the page.

Other recent news headlines

Differences in the performance of commonly used HIV tests lead to substantial differences in the number of infections which are diagnosed in everyday clinical practice, according to an analysis from San Francisco published last month in PLOS ONE. If the test used only detects HIV antibodies, most acute (recent) HIV infections are missed, with the OraQuick rapid test also missing established infections when testing saliva samples.

Three-quarters of infectious disease specialists in the United States and Canada are supportive of HIV pre-exposure prophylaxis (PrEP), but only 9% have prescribed the treatment, results of a survey published in the online edition of Clinical Infectious Diseases show. The study is the largest-ever survey of physician attitudes towards PrEP.

A short course of antiretroviral therapy during primary HIV infection (PHI) has immunological and virological benefits after treatment is stopped, a meta-analysis published in the online journal PLOS ONE shows. The benefits of treatment were greatest for people with lower baseline CD4 cell counts and higher baseline viral loads, but did not last in the long term.

Gillespie,
who has also been deputy chief executive at Breast Cancer Care and
chief executive of the Roy Castle Lung Cancer Foundation, will take up
the post in April. She is currently chief executive of the HIV awareness
charity Avert.

Pre-exposure prophylaxis (PrEP) is a sort of seatbelt for gay men, and it's no more a licence for promiscuity than a seatbelt is a licence for speed: for some users it may be, but not for most. The culture at large, including many gay survivors of the '80s and '90s, need to rethink their biases and assumptions – yes, it is possible now to have safe, unprotected gay sex.

Registration for HIV Prevention England’s one-day conference looking at the Future of HIV Prevention in England is now open.

The conference aims are to: increase involvement and understanding of HIV Prevention England, including It Starts With Me and National HIV Testing Week; share and discuss the latest developments in HIV prevention; and facilitate the identification, transfer and adoption of good practice.

It is taking place in central London on Thursday 20 February 2014, places are FREE but limited.

Further details, including the conference
programme, are available on the website.

NAM is an award-winning, community-based organisation, which works from the UK. We deliver reliable and accurate HIV information across the world to HIV-positive people and to the professionals who treat, support and care for them.